Department of Neurological Surgery, Hospices Civils de Lyon, Lyon, France.
Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA.
Stroke Vasc Neurol. 2024 Jun 21;9(3):221-229. doi: 10.1136/svn-2023-002380.
Cerebral cavernous malformations (CCMs) frequently manifest with haemorrhages. Stereotactic radiosurgery (SRS) has been employed for CCM not suitable for resection. Its effect on reducing haemorrhage risk is still controversial. The aim of this study was to expand on the safety and efficacy of SRS for haemorrhagic CCM.
This retrospective multicentric study included CCM with at least one haemorrhage treated with single-session SRS. The annual haemorrhagic rate (AHR) was calculated before and after SRS. Recurrent event analysis and Cox regression were used to evaluate factors associated with haemorrhage. Adverse radiation effects (AREs) and occurrence of new neurological deficits were recorded.
The study included 381 patients (median age: 37.5 years (Q1-Q3: 25.8-51.9) with 414 CCMs. The AHR from diagnosis to SRS excluding the first haemorrhage was 11.08 per 100 CCM-years and was reduced to 2.7 per 100 CCM-years after treatment. In recurrent event analysis, SRS, HR 0.27 (95% CI 0.17 to 0.44), p<0.0001 was associated with a decreased risk of haemorrhage, and the presence of developmental venous anomaly (DVA) with an increased risk, HR 1.60 (95% CI 1.07 to 2.40), p=0.022. The cumulative risk of first haemorrhage after SRS was 9.4% (95% CI 6% to 12.6%) at 5 years and 15.6% (95% CI% 9 to 21.8%) at 10 years. Margin doses> 13 Gy, HR 2.27 (95% CI 1.20 to 4.32), p=0.012 and the presence of DVA, HR 2.08 (95% CI 1.00 to 4.31), p=0.049 were factors associated with higher probability of post-SRS haemorrhage. Post-SRS haemorrhage was symptomatic in 22 out of 381 (5.8%) patients, presenting with transient (15/381) or permanent (7/381) neurological deficit. ARE occurred in 11.1% (46/414) CCM and was responsible for transient neurological deficit in 3.9% (15/381) of the patients and permanent deficit in 1.1% (4/381) of the patients. Margin doses >13 Gy and CCM volume >0.7 cc were associated with increased risk of ARE.
Single-session SRS for haemorrhagic CCM is associated with a decrease in haemorrhage rate. Margin doses ≤13 Gy seem advisable.
脑动静脉畸形（CAVM）常表现为出血。立体定向放射外科（SRS）已被用于不适合切除的 CAVM。其降低出血风险的效果仍存在争议。本研究旨在探讨 SRS 治疗出血性 CAVM 的安全性和有效性。
本回顾性多中心研究纳入了至少有一次出血且接受单次 SRS 治疗的 CAVM 患者。计算 SRS 前后的年出血率（AHR）。采用复发事件分析和 Cox 回归评估与出血相关的因素。记录不良放射效应（ARE）和新发神经功能缺损的发生情况。
研究共纳入 381 例患者（中位年龄：37.5 岁（四分位距：25.8-51.9），共 414 个 CAVM。从诊断到 SRS （排除首次出血）的 AHR 为 11.08/100 CCM-年，治疗后降至 2.7/100 CCM-年。在复发事件分析中，SRS（HR 0.27（95%CI 0.17-0.44），p<0.0001）与出血风险降低相关，而发育性静脉异常（DVA）与出血风险增加相关（HR 1.60（95%CI 1.07-2.40），p=0.022）。SRS 后首次出血的累积风险在 5 年时为 9.4%（95%CI 6%-12.6%），在 10 年时为 15.6%（95%CI 9%-21.8%）。边缘剂量>13 Gy（HR 2.27（95%CI 1.20-4.32），p=0.012）和存在 DVA（HR 2.08（95%CI 1.00-4.31），p=0.049）是与 SRS 后出血风险增加相关的因素。381 例患者中有 22 例（5.8%）出现 SRS 后出血，表现为短暂性（15/381）或永久性（7/381）神经功能缺损。414 个 CAVM 中有 46 个（11.1%）出现 ARE，其中 3.9%（15/381）的患者出现短暂性神经功能缺损，1.1%（4/381）的患者出现永久性神经功能缺损。边缘剂量>13 Gy 和 CAVM 体积>0.7 cc 与 ARE 风险增加相关。
SRS 治疗出血性 CAVM 可降低出血率。建议边缘剂量≤13 Gy。
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